When victims of 'looksmaxxing' end up in your clinic: A clinical rundown

Looksmaxxing has shifted from niche forum culture into mainstream adolescent and young adult health behavior. NPR has reported growing concern among adolescent boys, including steroid use, elective cosmetic surgery interest, and bone-smashing.^[]

Child psychiatrist Gene Beresin, MD, told NPR that he has “never seen anything like it before” in more than 40 years of practice.

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In a video posted on YouTube, board-certified dermatologist and founder of VR Skin Clinic, Rekha Kumar, MD, said, “I always first try to rule out body dysmorphia in patients motivated by social media. But looksmaxxing patients do not all need psychiatric referral; some need acne care, orthodontics, nutrition counseling, or cosmetic counseling. Some need urgent trauma assessment.”

Screen for body dysmorphic disorder (BDD) early, especially before cosmetic referral. BDD is associated with excessive mirror checking, comparison, camouflaging, reassurance seeking, skin picking, excessive grooming, and distress over perceived defects.^[] Global prevalence is estimated at 2% to 3%, 2% to 5% in US adolescents, 13% in general cosmetic surgery clinics, and 20% among patients pursuing rhinoplasty. The Body Dysmorphic Disorder Questionnaire has reported sensitivity of 100% and specificity of 89% to 93% for BDD diagnosis in psychiatric, cosmetic, surgery, and dermatology samples, followed by clinical interview.^[]

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Make appropriate referrals

“One trend that [is] way more scary than the others is bone-smashing,” Dr. Kumar adds. Bone-smashing is the practice of repeatedly hitting the face with a hard object in an attempt to change cheekbone, jaw, or facial structure.

Bone-smashing needs a trauma pathway. “Ask about timing, object used, number of strikes, loss of consciousness, vision changes, diplopia, malocclusion, trismus, dental injury, numbness, headache, epistaxis, vomiting, or escalating self-injury. Examine for periorbital injury, facial asymmetry, crepitus, sensory deficit, intraoral laceration, dental trauma, and mandibular tenderness,” Dr. Kumar says. 

Diana Kennedy, MD, a plastic and reconstructive surgeon at Mater Private Hospital Brisbane, told Mater News, “Repeated trauma to the face with a hammer or blunt object can cause soft tissue swelling, and bony microfractures, but this does not translate to improved appearance.”^[]

As for mewing-induced jawline complaints, Dr. Kumar says, “Patients with malocclusion, airway symptoms, pain, bruxism, or functional chewing issues deserve orthodontic or oral and maxillofacial evaluation. Appearance-only goals need expectation-setting.”

Identify psychological issues

“Many such cases have eating disorders, muscle dysmorphia, supplement toxicity, anabolic steroid exposure, stimulant misuse, depression, social withdrawal, and suicidal ideation,” Dr. Kumar says. “Men with muscle dysmorphia often pursue muscularity through rigid dieting, supplements, and sometimes steroids,” she adds.

Josef Hadeed, MD, a plastic surgeon in Beverly Hills, CA, told Fox News, “Even minimally invasive treatments carry real risks if performed incorrectly or by an untrained provider.”^[]

“Treat what is treatable,” Dr. Kumar says. She explains that issues such as acne, scarring, dermatitis, obesity, sleep apnea symptoms, malocclusion, and nasal obstruction deserve standard care. 

She Kumar also strongly recommends delaying elective cosmetic escalation when a patient’s distress is disproportionate, insight is poor, or the patient describes life as intolerable unless a feature changes. Instead, she says, consider referral for a psychological assessment.